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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �. <br /> APPLICATION . <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL,HEALTH PERMIT SEPTAGE <br /> s LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DSA) <br /> aOwner . !" Address <br /> �'� Address .� <br /> Firm Partners, Addresses and Telephone Numbers <br /> I <br /> IL <br /> Business Telephone No. �7 <br /> Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) <br /> ,72 Please check Applicable Category ) Title r / I /" . Date <br /> PP g ry{1-7 and Fill in the Required Information � j <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Jul 1, '`�T' — <br /> Y June 30,:19Disposal Sites <br /> Description(Make/Yr., Color) y - .; _J ' <br /> Serial No. CAL, License No. P <br /> Capacity <br /> Gal., Weights & Measures No. CAL. License Renewal No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, _ June 30, 19 I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilet's Stored <br /> 3. ❑ PERCOLATION TEST _ X1, <br /> R.S. or R.C.E. Name{ - I N <br /> Test ocatioR <br /> R.S. or R.C.E. No, hV <br /> � <br /> 4- SANITATION PERMIT ilt S Zo Test Date/Time <br /> Job Address/Location Q i <br /> Ownery ,p^� Address / 4_ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ <br /> ❑ PERMANENT ❑ TEMPOR_ARY ❑ NEW }x SEEPAGE PIT 11 PACKAGE PLANT <br /> 5• <br /> El CHEMICAL TOILETS-For July.7;-June 30, 19 REPAIR 13 OTHER <br /> Type Construction >1r Disposal Site �. <br /> No. of Units FEquipment Storage/Cleaning Location(s) ; <br /> 6. ❑ PACKAGE TREATMENT PLANT,,.For July 1, -June 30, 19 � 1� <br /> Operator Name <br /> Plant Location <br /> Where Certified <br />'Plant Capacity No. Units Served + <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.) <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. + <br /> 4 A JFS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C <br /> ordinances, state lawsn rules and r9oations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �$ U <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - REMIT <br /> DATE DAT REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER l/ <br /> [ ti <br /> OTHER i <br /> L Received,by Date �4 SCC <br /> =� Receipt No. Permit No. Issuance Date - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESMailed Delivered ' <br /> 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 ' <br />